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oPqV("' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ' < SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone: (209)468-3454 Fax: (209) 468-3433 Web:www.sigov.ora/ehd <br /> �`Jppfii� <br /> WELL & BORING PERMIT APPLICATION o nJ <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J U <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance wl h San <br /> Joaquin County Development Title,Chapter 9-1115 3,and the Standards off tth�e San Joaquin County Environmental Health Department. <br /> Site Location �s Cross Street 5. 9A4q -/-y�iK.t((--f� city Z 7Zip gJ`�3150 APN l�g-o?1-10 <br /> Own <br /> Property P(CkG ILL. �� (OTV✓1 I JC ?✓V6q Phone p �� <br /> Owner Address City r` Zip <br /> C-57 Contractor Address Q Cowin k/A City G +'� Lic ��al�tSo _ slL7 <br /> ConsultanUSub Cntr Address 30/7 0 Sk/GU City 1W(0144 Lic Phone 9l�' <br /> Billable Party _ _ Address City Zip Phone <br /> GIS Coordinates:X •RI I^Ys—j2!• �� <br /> CONSTRUCTION WORK TO BE PERFORMED:IQ (( <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER) w <br /> Q,SOIL BORING IDs ` <br /> LL IDsQ _ <br /> r4OFWELUBORING <br /> HER IDs�Is- flyy&!4 r'�� IV <br /> TYPE INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _[E]MONITORING [IHOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ��V G✓ <br /> 3(EXTRACTION Vapor Ater ❑HAMMER/DRIVEN CASING THICKNESS CATV TYPE OF CASING: C]STEEL PVC OTHER_ <br /> _/❑ <br /> IS IL VAPOR PR ❑MUD ROTARY DEPTH OF GROUT SEAL rl TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING C1 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:I]Yes Q4 No(MA IMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i a AIrSD.rQg_Ozone) -HAND AUGER GROUT SPECIFICATIONS ?0 <br /> X_❑OTHER:Soil V Or W4 115 ❑OTHER: APPROX.BORING DEPTH SI BOLTED TRAFFIC BOX R ❑STOVE PIPE <br /> CONDUCTOR C So(WI G 0,No❑Yes Casing Dia: asing Dep1h: Boring Dia: <br /> COMMENTS /�? <br /> : <br /> NOTE: OFFSITE WELLS& BORINGS REQUIR9 ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 1 <br /> #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS _ <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and ap a I ble C tifo is laws. <br /> Signed Title/Company <br /> Print Name Dae <br /> DEPARTMENT USE ONLY V Lam <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED V <br /> APPLICATION ACCEPTED BY DATE ISSUED ��'� AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DAT SERVICE RO# INVOICE <br /> REQUEST PR# <br /> �j5o1 <br /> $122x 3 3� /� !� SR# Ohl 7,$ <br /> 35 <br /> 03 3�� 3� (300 os6 <br /> PR# <br /> 2900 <br /> 3-57 WC WAIVER 1y1A C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT D <br /> EH029-Ot 07!28110 ,SLE <br /> P <br />